Background: The frequency of ROS1 rearrangement in non-small cell lung cancers has been reported from 1.6% to 2.3%. Materials and Methods: We examined 105 lung adenocarcinoma patients for ROS1 rearrangement which were negative for EGFR and anaplastic lymphoma kinase. Clinical characteristics of ROS1 rearranged patients and their responses to crizotinib therapy were studied. Results: Of the 105 patients, three cases were positive for ROS1 rearrangement by fluorescence in situ hybridization analysis. All of them showed heterogeneous pattern. All the 3 ROS1-positive patients were females in their forties and started on crizotinib. All of them responded to treatment. One of them developed resistance after 3 months. Another one showed marked systemic response but central nervous system lesions progressed. The third case is doing well till date with inactive lesions on positron emission tomography scan. Conclusions: The frequency of ROS1 rearrangement is low in non-small cell lung carcinoma, but their diagnosis offers patients an opportunity to receive highly effective targeted therapies.

Context: Irreversible airway obstruction is important sequelae of pulmonary tuberculosis (TB) that might contribute to a significant proportion of chronic obstructive pulmonary disease (COPD). India has the highest TB burden in the world. However, there are limited data on the prevalence and presentation of TB-associated COPD from this region. Aims: This study aims to evaluate the prevalence of TB-associated COPD among COPD patients presenting to a tertiary care hospital. Settings and Design: It was a case–control study conducted in a tertiary care hospital. Subjects and Methods: Stable COPD patients presenting to chest OPD and an equal number of healthy controls were enrolled. COPD patients were subjected to detailed clinical evaluation and lung function test. History of pulmonary TB was evaluated from both groups through self-reporting and/or checking previous records. TB-associated COPD patients were identified and their prevalence and distinguishing features evaluated. Results: Of 74 COPD patients, 24 (32.4%) had previous history of pulmonary TB. The odds of having a previous TB in COPD patients was 3.96 (95% confidence interval: 1.64–9.55; P = 0.002) as compared to controls. Patients with TB-associated COPD were younger (P = 0.02), had lesser pack-years of smoking (P = 0.027) but had more number of hospitalizations (P = 0.01). The airflow limitation was similar in both groups. Conclusions: TB-associated COPD constitutes a significant proportion of COPD patients. It is a distinct clinical entity with preponderance in young. It may be associated with frequent hospitalizations as compared to other COPD patients.

Introduction: Tracheal stenosis is a complex condition caused by altered inflammatory response to injury and subsequent excessive circumferential scar formation. Surgical resection, wherever possible, offers the best long-term results. Nonsurgical methods provide immediate relief to all can be curative in few but mostly serve as an excellent bridge to surgery in majority. The purpose of this study is to retrospectively evaluate the outcome following surgery for benign tracheal stenosis at our center. Materials and Methods: This retrospective analysis was conducted on 18 patients who underwent resection and anastomosis for tracheal stenosis at our center between March 2012 and December 2015. Their records were analyzed for demography, history, clinical presentation, computed tomography, bronchoscopy details, preoperative interventions, indications for and details of surgery, the procedure performed, postoperative complications, and course during 6 months follow-up. Results: The patients had a varied list of pathologies for which they were either intubated or tracheostomized. The length of stenosis ranged between 1 cm and 4 cm. The diameter of stenotic segment ranged between 0 mm and 10 mm. Average length of resected segment was 3 cm, and number of tracheal rings resected ranged from 2 to 9. Postoperative complications occurred in four patients (22.22%). All our patients were in the “excellent outcome” category at discharge as well as at 3 months follow-up. Conclusions: Surgical management of tracheal stenosis is challenging and requires multidisciplinary team approach. Thorough preoperative preparation and multidisciplinary planning regarding need for and timing of surgery, meticulous intraoperative technique, and aggressive postoperative care is key to successful surgery, which can provide long-lasting cure to these patients.

Background: Individualized treatment for multidrug-resistant tuberculosis (MDR TB) is associated with improved outcomes. Therapy needs to be tailored to drug susceptibility testing (DST) results. We present our observations on the inconsistency in DST reporting in an endemic region with a high prevalence of MDR TB. Methods: We retrospectively analyzed 118 DST reports from 10 different laboratories. Observations: Of 118 patients, only 79 (67%) had DST reports with results to all first-line drugs, a fluoroquinolone (excluding ciprofloxacin), all aminoglycosides, and a polypeptide. Twenty-one (18%) isolates did not have DST reports for all first-line drugs; 4 (3%) did not have DST reports for any second-line drugs; 9 (8%) did not have DST reports for a fluoroquinolone; and 31 (26%) did not have DST reports for all second-line aminoglycosides and polypeptide. Conclusion: Inconsistencies were observed in several of the 118 DST reports. A case is made for sensitization toward standardization and completeness in TB DST reporting in India.

Background: Mycobacterium tuberculosis (MTB) Beijing strains are spread worldwide and are responsible for major outbreaks of tuberculosis (TB), sometimes spreading multidrug resistance (MDR). Aim: The aim of this study was to explore clinical features associated with the infection with Beijing strains among MDR patients of pulmonary TB in Lucknow and surrounding areas. Materials and Methods: It was a hospital-based epidemiological study. Our study population was selected from all the newly diagnosed patients attending outpatient department and admitted patients of Department of Respiratory Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India. Those isolates which were characterized to be MTB by morphological and molecular techniques were tested for their resistance against the first-line drugs; after which each patient's isolate was genotyped. Results: The results suggested that the presence of Beijing genotype in 31.78% of strains. Conclusion: Our results predicted that genotypic patterns reveal a large diversity among the MTB Beijing strain population. Increasing frequency of Beijing strains demands further research to unravel the factors behind its propensity to prevail.

Aim: This study aimed to evaluate the phenomenology of delirium in patients admitted in a Respiratory Intensive Care Unit (RICU). Methods: Consecutive patients admitted to RICU were screened for delirium using Richmond Agitation-Sedation Scale (RASS), Confusion Assessment Method for ICU (CAM-ICU) assessment tool and those found positive for delirium were evaluated by a psychiatrist to confirm the diagnosis. Those with a diagnosis of delirium as per the psychiatrist were evaluated on Delirium Rating Scale-Revised-98 (DRS-R-98) to study phenomenology. Results: All the 75 patients fulfilled the criteria of “acute onset of symptoms” and “presence of an underlying physical disorder” as per the DRS-R-98. Commonly seen symptoms of delirium included disturbances in attention (100%), thought process abnormality (100%), fluctuation in symptoms (97.33%) disturbance in, sleep-wake cycle, language disturbance (94.7%), disorientation (81.33%), and short-term memory impairments (73.33%). No patient had delusions and very few (5.3%) reported perceptual disturbances. According to RASS subtyping, hypoactive delirium was the most common subtype (n = 34; 45.33%), followed by hyperactive subtype (n = 28; 37.33%) and a few patients had mixed subtype of delirium (n = 13; 17.33%). Factor structure of DRS-R-98 symptoms yielded 3 factors (Factor-1: cognitive factor; Factor-2: motoric factor; Factor-3; thought, language, and fluctuation factor). Conclusion: The phenomenology of delirium in ICU patients is similar to non-ICU patients, but hypoactive delirium is the most common subtype.

The most efficient and cost-effective approach for the diagnosis of pleural exudates remains uncertain and is a subject of controversy. Essential factors to be considered include the respective diagnostic yields of thoracocentesis, closed pleural biopsy, and thoracoscopy. The role of endoscopic ultrasound (EUS) of the esophagus as a modality for the evaluation of pleural exudates has not yet been evaluated. The applied anatomy of the pleura has been discussed. The techniques involved in the EUS imaging of different aspects of the pleura in normal cases and in cases with pleural effusion are elaborated. The practical application of this knowledge can be useful in EUS-guided sampling of the pleural wall, pleural nodules, and in cases of pleural effusion.

Transtracheal oxygen therapy is a well-established modality for improving oxygenation in patients with chronic obstructive pulmonary disease, sleep apnea, pulmonary fibrosis, and other conditions causing hypoxic respiratory failure. In spite of its proven track record, the device remains underutilized. This article reviews benefits and complications related to the use of this modality with an illustrative case presentation.

Viral influenza is a seasonal infection associated with significant morbidity and mortality. Rapidly fatal hemorrhagic pneumonia has been described in previously healthy individuals with β-hemolytic Streptococcus pneumoniae in a small series of patients, but it is not common in patients coinfected with influenza B and β-hemolytic Streptococcus, particularly since influenza B is considered less pathogenic than influenza A. However, despite being uncommon, this coinfection seems to be associated with high morbidity and mortality, particularly in healthy individuals. We present a case of a 46-year-old previously healthy white woman presenting with 4 days of shortness of breath, sore throat, subjective fevers, and nonproductive cough with rapidly fatal hemorrhagic pneumonia confirmed to have Group A β-hemolytic Streptococcus and influenza B coinfection. On admission, she had a temperature of 103° F, room air oxygen saturation of 95%, a positive nasal swab for influenza B, and negative rapid strep test. Initial chest radiograph showed increased bibasilar interstitial markings. She was admitted to a regular floor and started on oseltamivir. Preliminary throat culture was positive for Group A β-hemolytic Streptococcus and penicillin V was started. Respiratory status deteriorated requiring intubation and transfer to Intensive Care Unit. Subsequently, copious bleeding was noted in her endotracheal tube. A bedside bronchoscopy with bronchoalveolar lavage revealed a hemorrhagic pneumonitis. Despite aggressive efforts, she developed shock, arrested, and died Western District Office of the Chief Medical Examiner, Roanoke, VA, USA postadmission. Blood cultures, bronchoalveolar lavage, and postmortem pulmonary tissue grew Group A β-hemolytic Streptococcus, only resistant to erythromycin.

Etiologic diagnosis of an eosinophilic pleural effusion (EPE) presents a diagnostic challenge when intrapleural air and blood have been ruled out as its proximate causes. Among the causes of EPE, those that require immunosuppression for the underlying disease include connective tissue diseases, sarcoidosis, vasculitis, and eosinophilic pneumonia. We present a case of clinically suspected Behcet's syndrome based on a 10-year history of recurrent multiple oral ulcers and human leukocyte antigen-B51 positivity who presented with only an EPE. Computed tomography pulmonary angiogram ruled out central thoracic vein thrombosis but was inconclusive in ruling out a subsegmental pulmonary embolism. The patient declined immunosuppressants and while on follow-up developed bilateral extensive acute lower limb deep venous thrombosis and pulmonary embolism. Upper infrarenal inferior vena cava demonstrated chronic thrombosis suggestive of its antecedent role in pulmonary embolism-related EPE during the first instance. Behcet's syndrome-related EPE can be associated with venous thromboembolism, and immunosuppressive therapy prevents the subsequent thrombotic episodes.

Eosinophilic lung diseases are a diverse group of pulmonary disorders with an extensive list of differential diagnoses. Multiple drugs particularly antibiotics can cause pulmonary eosinophilia with variable pulmonary manifestations. Cutaneous drug reactions are common. Diagnosis is usually made on clinical history and blood eosinophilia with an accumulation of eosinophils in alveolar spaces on histologic analysis. Imaging findings are nonspecific. Stopping the offending agent is often enough while a short course of corticosteroids can hasten recovery. We present a unique case of eosinophilic pneumonia due to meropenem that highlights the importance of keeping a low threshold of suspicion regarding the etiology of drug-induced lung diseases as the current list is not exhaustive, and new agents are being identified continuously. A 51-year-old African American woman presented with fever, dyspnea, and diffuse pustular rash. She had been treated with meropenem intravenously through a peripherally inserted central catheter for 6 weeks before presentation for Pseudomonas aeruginosa septic arthritis of the left knee. She had a temperature of 102.2 F and SpO₂of 86% on room air. Chest roentgenogram had scattered infiltrates and chest tomography showed bilateral ground-glass opacities. Laboratory workup showed peripheral eosinophilia. Bronchoalveolar lavage revealed a white blood cell of 2230 with 89% eosinophils. Skin lesions' biopsies showed pustular dermatosis, compatible with acute drug-induced eosinophilic lung disease with skin involvement. As meropenem was the only medication she had been exposed to, it was stopped and systemic steroids were initiated with improvement in respiratory and clinical status and complete recovery on follow-up.

Suicidal hanging causes damage to the airways, neck blood vessels as well as soft tissue injuries. We report the development of tracheo-esophageal fistula in such a patient. Recurrent soiling of the airways and the resultant lung infection led to weaning failure. We highlight the approach to diagnosis and appropriate management in such a patient.

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is usually performed under moderate sedation through the oral approach. Oral insertion is performed owing to the larger size of the EBUS bronchoscope as well as the delicate and rigid distal end with an integrated ultrasound transducer assembly. Nasal route for EBUS scope insertion has been described as a feasible alternative. We herein report a patient wherein inability to introduce the EBUS bronchoscope through the mouth necessitated nasal insertion of the bronchoscope to successfully perform EBUS-TBNA. We discuss the relevant issues comparing the nasal and oral introduction of the EBUS bronchoscope.

Introduction: Idiopathic pulmonary fibrosis (IPF), a chronic progressive interstitial lung disease (ILD), Occasionally, IPF occurs in families. Familial interstitial lung disease has been reported worldwide, limited information is available on the disease among Indian patients. Case Presentation: A 59-year-old woman presented with a 2-year history of progressive dyspnoea. Based on clinical and radiological features, our patient was diagnosed with idiopathic pulmonary fibrosis. Several family members of her first and second generations had died from respiratory failure. Her sister also diagnosed as IPF based on typical High resolution computed tomography (HRCT) finding though she was asymptomatic and came for screening. In addition, another male patient also had similar history and diagnosed as familial IPF based on HRCT and genetic testing in spite of significant occupational exposure. Genetic study revealed SFTPA1 gene was associated with susceptibility to idiopathic pulmonary fibrosis. Conclusion: Our report illustrates that asymptomatic screening of family member can uncover such a serious disease in patients with familial interstitial fibrosis. Otherwise, clinical, radiological, and histological features are indistinguishable from those of sporadic cases. Furthermore, our work highlights the importance of compiling a thorough family history in individuals presenting with cough and dyspnoea, particularly in younger patients identified with idiopathic pulmonary fibrosis.